Amebic Liver Abscess

Key Features

Essentials of Diagnosis

• Fever, abdominal pain

• Amoebae or antigen in stool or abscess aspirate

• Positive serologic tests but may represent prior infections

• Hepatomegaly, hepatic abscess on imaging studies

General Considerations

• The Entamoeba complex contains three morphologically identical species

  • E dispar, which is avirulent

  • E moshkovskii, which is also avirulent

  • E histolytica, which may be an avirulent intestinal commensal or lead to serious disease

• Humans are the only established host for E histolytica

• Transmission occurs through ingestion of cysts from fecally contaminated food or water

• Infection can be transmitted person-to-person

• Flies and other arthropods also serve as mechanical vectors

• Disease follows penetration of the intestinal wall, resulting in

  • Diarrhea

  • Dysentery

  • Extraintestinal disease, most commonly liver abscess

Demographics

• E histolytica infections are present worldwide but are most prevalent in subtropical and tropical areas under conditions of crowding, poor sanitation, and poor nutrition

• Of 500 million persons worldwide infected with Entamoeba, most are infected with E dispar and an estimated 10% (50 million) are infected with E histolytica

• Mortality from invasive E histolytica is about 100,000 per year

• Severe disease is more common in

  • Young children

  • Pregnant women

  • Persons who are malnourished

  • Persons receiving corticosteroids

• Hepatic abscesses more common in men

Clinical Findings

Symptoms and Signs

• Many patients do not have current or a past history of intestinal symptoms

• Acute or gradual onset of abdominal pain

• Fever

• Enlarged and tender liver

• Anorexia

• Weight loss

• Intercostal tenderness

• Diarrhea is present in a small number of patients

• Abscesses are most commonly single and in the right lobe of the liver

• Amebic infections may rarely occur throughout the body, including the lungs, brain, and genitourinary system

Differential Diagnosis

• Pyogenic liver abscess

• Echinococcosis (hydatid disease)

• Cholecystitis or cholangitis

• Right lower lobe pneumonia

• Pancreatitis

• Hepatocellular carcinoma

Diagnosis

Laboratory Tests

• Leukocytosis and elevated liver biochemical tests

• Serologic tests for anti-amebic antibodies are almost always positive, except very early in the infection

• Thus, a negative test in a suspicious case should be repeated in about a week

• The stool E histolytica antigen test is positive in ~40% of cases; the TechLab II test can also be used to test serum, with good sensitivity if used before the initiation of therapy

• Examination of stools for the organisms or antigen is frequently negative

Imaging Studies

• Ultrasonography, CT, or MRI show abscesses as round or oval low-density nonhomogeneous lesions with abrupt transition from normal liver to the lesion and hypoechoic centers

Diagnostic Procedures

• Percutaneous aspiration

  • May be ...